For doctors, every day at work seems to be a new beginning. During routine ward rounds in the morning, they may have to take on new patients. Although they are basically familiar with every patient they are responsible for, even if they cannot memorize the cases,
When you come out, you can at least remember the patient's basic condition and treatment plan.
However, every patient's condition cannot be exactly the same every day, so for resident doctors, daily ward rounds are very important.
A new patient came in today. The patient's name is Jillian.
Jillian was admitted to the hospital because of edema in both lower limbs without obvious triggers. Mainly in the ankles, accompanied by fatigue and frequent dreams at night. There was no history of fever, cough, palpitations, chest tightness, headache, low back pain, or hematuria, and no history of medication before the illness.
One month ago, the edema extended to below the umbilicus, accompanied by shortness of breath, chest tightness, and inability to lie down at night.
Physical examination: body temperature 37C, pulse 140 beats/min, respiration 28 breaths/min, blood pressure 149/110mmhg. Normal development, moderate nutrition, chronic disease appearance, clear mind, slightly short of breath, passive semi-recumbent position, transported to the ward by car, and answered questions
To the point, cooperate with the examination. There is no jaundice or bleeding spots on the skin or mucous membranes, no rash, spider veins on the skin or liver palms. There is no swelling of the superficial lymph nodes. There are no deformities in the facial features of the head, mild swelling of the eyelids and face on both sides, and equal round pupils on both sides.
Equal size, light reflection exists. The neck has no resistance, the trachea is in the middle, and the thyroid is not enlarged. The jugular veins are full. The bilateral thorax is symmetrical, there is no edema on both chest walls, the respiratory movements are equal on both sides, the percussion is voiceless, and the breath sounds in both lungs are clear.
, no wet or dry rales were heard. There was no bulge in the precordium area, the apical pulse was not significant, the heart boundaries were enlarged bilaterally, the heart sounds were low and dull, the heart rate was fast, the heart rate was 140 beats/min, and the heartbeat was irregular. II could be heard in the apical area.
/Grade 6 systolic murmur. Abdominal distension, no mass, no tenderness, no rebound tenderness, unsatisfactory palpation of the liver, spleen and ribs, no percussion pain in the liver and kidneys. Shifting dullness is suspiciously positive, bowel sounds
The sound is present. There is no deformity in the spine and limbs, and the activities are normal. There is pitting edema in the abdomen below the umbilical cord, the perineum, and both lower limbs. The right lower limb is thicker than the left lower limb, and the skin is tight. The hands are slightly swollen. There is no gunshot sound and no capillary pulsation sign.
The muscle strength of both upper limbs was grade 5, and the muscle strength of both lower limbs was grade 4+. The muscle tone of the limbs was normal. Physiological reflexes were present. Pathological reflexes were not elicited.
Chest X-ray: The heart shadow is generally significantly enlarged, considering cardiac insufficiency, congestion in both lungs, and a small amount of pleural effusion on both sides. Abdominal B-ultrasound: Congestive hepatomegaly; abdominal effusion (a small amount); B-ultrasound of both lower limbs:
Gastrocnemius vein thrombosis in the middle and upper part of the right calf. Two electrocardiograms: low voltage (limb leads), 4:3 atrial flutter; the other one was rapid atrial fibrillation.
Dai Linsi showed the medical records to everyone, and then asked the question, "Everyone, please tell me your diagnosis. Why did the patient have such severe edema? Also talk about the next steps that need to be completed and the treatment plan."
.”
Because the patient's condition is complex and serious, there are many examination items. This is not a very common thing at Johns Hopkins Hospital because the outpatient clinic and pharmacy, as well as the examination and treatment areas are separated. Any
Inspections need to be booked in advance.
Jillian has been to other hospitals for treatment and has been hospitalized for a long time. Because there was no effect, she was transferred to Johns Hopkins Hospital. In Baltimore, Johns Hopkins Hospital is naturally the best in the city.
Hospitals often receive difficult cases transferred from community hospitals.
Spacey immediately jumped in and said, "I'll go first."
Dai Linsi nodded and gave Spacey an encouraging look.
Spacey was ecstatic. It seemed that famous American doctors would finally get a chance to stand out in the future. "I think we can consider the following possibilities. 1. Chronic cardiac insufficiency: elderly female, accompanied by accelerated heart rate, chest tightness, and edema of both lower limbs.
Cardiac insufficiency is highly likely. Complete BNP, cardiac color Doppler ultrasound, etc. can help diagnose. 2. Chronic renal insufficiency: The patient has proteinuria (+) and has obvious symptoms such as edema and fatigue. Chronic renal insufficiency is generally not present in the early stages.
Special symptoms can be considered. Checking kidney function and quantitative urine protein measurement can help diagnose. 3. Hepatic origin. The patient's liver function is slightly damaged and the total protein is not particularly low. It is considered that the edema is not caused by hypoalbuminemia and should be ruled out.
4. Hyperthyroidism: Both hyperthyroidism and hypothyroidism can be accompanied by edema, but this can be ruled out by checking thyroxine. 5. Venous thrombosis of the lower limbs: often manifests as limb edema, and the edema is severe. It is generally not accompanied by systemic symptoms, so it can be ruled out.
6. Tumor: Pelvic tumors cause edema due to obstruction of venous return in the lower limbs, and ascites and even pleural effusion produced by tumors can produce corresponding symptoms. 7. Infection: currently not considered. 8. Autoimmune diseases. The reason why edema is still serious at present is
Because on the one hand, the cause of the disease has not been eliminated, and the kidney function is indeed damaged. Third, in a long-term high-power circulation state, short-term reduction of blood volume and tissue fluid volume will cause related reactions in the body. Improve examination,
BNP, cardiac color ultrasound, coagulation function, renal function, 24-hour urine protein quantitative measurement, pelvic m-day, chest and abdomen CT, etc. Beta blockers cannot be used, on the one hand, it is easy to induce arrhythmia, and on the other hand, it is easy to cause heart rate problems.
Slowing down and triggering the occurrence of pulmonary edema.”
After Spacey finished speaking, he looked at everyone with some pride.
"You talk so much, but only a few are really useful. Can you just tell me the disease and how to cure it soon?" Deborah couldn't stand the arrogance of a future famous doctor in the United States.
Spacey chuckled and said: "Deborah, if you think my diagnosis is not good, you can tell me your opinion. Dr. Dai Lins must be willing to see that we are serious about disease diagnosis."
"Just say it, what's the big deal?" Deborah pouted and said. This girl was very angry at the future famous American doctor.
"Everyone be quiet, Deborah has something to say." Spacey clapped his hands.
"I am diagnosed with heart failure. If the edema continues to worsen during cardiotonic and diuretic treatment, the first thing to consider is the kidney function. You should ask about the daily urine output at the beginning and consider the kidney function. If renal failure occurs, the edema will of course worsen. The next step is to check the kidney function first.
, consider the cause of heart failure, it is heart failure caused by kidney failure." Deborah expressed her point of view. But before Deborah could finish her words, Spacey already laughed out loud.
"You call this an answer? You still have several unanswered questions about Dr. Dailins." Spacey had a sarcastic look on his face.
"My answer is very short, but very intuitive. It's not like someone who talks a lot and only endorses it. He doesn't even know what he is talking about." Deborah immediately counterattacked.
Dai Linsi looked at the two idiots he brought with him helplessly: "You should also share your opinions."
The situation of this case is really complicated, so the diagnosis of the disease by several trainees is very different. Western medicine relies on advanced instruments and equipment. Jillian's examination items were numerous, but these results were not enough for the doctor to make a diagnosis.
to make a correct judgment. As a result, everyone's answers had a somewhat uncertain tone.
"Qin, why don't you tell me your opinion?" Deborah asked.
"Although the case description is very detailed, it is a medical record after all. I think it is better to do some simple examinations on the patient, and it does not necessarily need to rely on equipment. We say that the patient's condition can be seen from the patient's complexion. In addition,
Some routine inspections can also help us make the right choice," Qin Chuan said.
Dai Linsi nodded: "Okay, let's go over and see this patient with our own eyes."
Spike and Deborah were both a little puzzled.
"Didn't you already see the patient just now? Why do we still need to conduct an examination?" Spacey asked in confusion.
Deborah didn't understand at first, but since someone already didn't understand, she naturally couldn't show it.
"Qin, aren't you mistaken? Even if you check it yourself, can you get more detailed results than this?" Emerson asked.
Qin Chuan shook his head: "Although I can't get more detailed results than this, there are advantages to personal inspection."
This is Qin Chuan's advantage. He once worked in the emergency department. There was a time when he was in an emergency. Before there was a universal first aid kit, Qin Chuan and his colleagues had to rely on experience to judge the patient's condition in advance.
Healing buys time.
Tajira also disagreed with Qin Chuan's words: "What we learn in school is how to use advanced medical equipment instead of relying on personal experience to see a doctor. Because personal experience always has a certain degree of subjectivity, it is very difficult to
It is easy to end up with misdiagnosis due to personal subjective consciousness. When we judge a disease, we always have specific conditions and are very strict. Although this strict procedure may seem a bit dogmatic, it can help us make fewer mistakes."
Dai Linsi seemed to want to say something, but took it back, but still gave Qin Chuan a chance, "Qin, make a diagnosis according to your method."
Qin Chuan did some simple checks on Jillian and took Dai Linsi's pulse.
Although Spike didn't understand what Qin Chuan meant by checking his pulse, he could see that Qin Chuan's way of checking was much weirder than ordinary checks.
"Qin, did you find anything during the examination?" Shi Paixi was a little curious about Qin Chuan's examination.
The rest of the trainees, as well as Dai Linsi and others, all focused their attention on Qin Chuan. They were eager to know Qin Chuan's diagnosis results.
Qin Chuan didn't say anything. He wrote a lot of things in the notebook.
Jillian didn't ask questions because she had already seen that, except for Dai Lins, the rest of the people were trainees. Their results were naturally not that convincing. (To be continued, please search Piaotian Literature, novels are better
